When normal is wrong

›› In the section headed “Learning points”, it is written: “The failure rate of vasectomy, either due to failure to remove adequate sections of both vasa or recanalisation, albeit small, is of crucial significance, and must be mentioned and documented.”

Unfortunately, this sentence implies that removing an “adequate section” of vas will prevent failure. Evidence from vasectomy randomised studies shows that the best way to prevent failure is to lightly cauterise the lumen of each vas and to separate the ends by a tissue plane. Separating the ends by a tissue plane but without luminal cautery is nearly as good. The older method of removing a long length of vas is associated with a higher complication rate (bleeding and pain) and higher recanalisation rate.

If any vas is removed then it should only be a small section, not an “adequate section”, as one has to remove a very long section to prevent end approximation and vasectomy failure. Removing very long sections is associated with an unnecessarily higher complication rate and also makes reversal much more difficult should circumstances change. The ideal vasectomy is minimally invasive, has minimal complications, is 100% effective and 100% reversible. No technique perfectly meets these criteria but the no-scalpel technique with fascial interposition and ideally with luminal cautery is the best we currently have.

Tim Hargreave, Consultant genito-urinary surgeon (retired), Current member, research review panel, human reproduction programme, WHO, Geneva. References have been supplied, and are available on request.

Suspected epilepsy: when to warn

›› It was stated in “Suspected epilepsy: when to warn” (Casebook 21(2)) that “there was nothing in the notes to suggest the hospital intended to rule out anything serious, like epilepsy”. Yet an EEG was arranged. I cannot conceive of a reason for EEG other than to rule out something serious – like epilepsy. The mere fact that it was arranged – isn’t it ample proof?

Moreover, presumably the patient’s parents were given the EEG appointment card or information before leaving the hospital; they then chose not to bring the patient for the EEG, without bothering to find out what the test was and what it was for. Don’t they bear some responsibility?

Dr Chun How Ooi, Singapore

Response

I agree with you that the statement you quote in your first paragraph is somewhat illogical.

Regarding the parents’ responsibility, courts generally are reluctant to hold a patient – or in this case the child’s parents – as contributing to the negligent outcome

Regarding the parents’ responsibility, courts generally are reluctant to hold a patient – or in this case the child’s parents – as contributing to the negligent outcome. You can imagine the persuasive power of a parent saying: “Of course if I had been properly informed of what the test was for and why it was important, I would never have knowingly put my child at risk...” And the notes usually do not document the detail of such a conversation.

Two cases: one theme

›› Two articles have a common theme. Patients in both cases sued their GP while the healthcare system and government policy neglected to ensure patient safety.

The healthcare industry should take steps to prevent chickenpox in pregnancy. We could have a national immunisation program [here in the UK] like that in the US (www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html). We could also check women for immune status at booking or preconception. As it is we rely on GPs remembering to follow a post-exposure prophylaxis protocol. Murphy’s Law applies so patients suffer and doctors pay, via indemnity subscriptions, to help clear up the mess.

Why does the healthcare system have us install a piece of electronics in a man’s chest without having a way to monitor it? The GP’s notes may have been poor but the responsibility for the device should rest with the company that made it and the clinic that inserted it. A cardiac pacemaker is a ‘mission critical’ device. If it stops the patient might die. In the case you describe recording the pulse or an ECG wouldn’t have given information about its activity over a period longer than a few seconds. There should be systems to ensure that it can’t fail without that failure being detectable in real time. At the very least there should be a way to interrogate it to determine how it has behaved in the past.

Why does the healthcare system have us install a piece of electronics in a man’s chest without having a way to monitor it?

In critical event analysis we should be looking at ways to improve patient safety. A simple measure would be to change the way we record blood pressure. The data entry box for BP using INPS Vision has no facility except free text for recording pulse rate. It would be very simple to add a mandatory field for pulse rate (and reg/irreg to screen for atrial fibrillation).

I want to see MPS analysing cases to identify areas where putting pressure on government health departments and their suppliers to change policy could prevent future disasters, and then applying that pressure.

Response

Many thanks for taking the trouble to write in with your response to two of the reports in the last edition of Casebook. It is useful for us to have feedback like this, and it informs our future publications and lobbying activities. We also plan to share such activities with readers in more detail, in future articles and updates.

A case of renal failure

›› I found “A case of renal failure” (Casebook 21(2)) rather worrying. It states that Dr T was criticised for failing to notice that Mrs B’s renal function had not been rechecked.

Mrs B had been advised by Dr T to have her bloods rechecked but if she failed to do so, then that is her fault. I see between 36-40 patients a day but do not make a list of which patients have not had the blood tests that I requested them to have.

Is MPS suggesting that this is what we should be doing?

Secondly, the report mentions that the GP should have sent a urine for ACR. My understanding is that an ACR should only be sent for diabetic patients and non-diabetic patients should have a PCR sent instead. Please do let me know if I am wrong in this regard.

Dr Muhammad Shahbaz Sharif, Salaried GP, Leicester, UK

Response

We acknowledge the practical challenges of having a system that will pick up patients who do not return with results of tests that have been ordered – it is a frequent source of debate as to whether a court would invariably hold the patient totally responsible for the consequences; a court might take the view that patients are less likely to act in a way that puts them at risk, if they understand those risks. However, there was no excuse for the GP not to have checked her renal function at subsequent visits, and the results were so significant as to suggest that the GP could not have explained the importance to the patient.

Finally I am advised that most CKD guidelines advise annual ACR checks, on all patients with an eGFR under 60, regardless of underlying aetiology.

I hope that this addresses the issues you raised.

A rash oversight

›› I read with interest your case report regarding the patient who was given incorrect medical advice by non-medical staff (“A rash oversight”, Casebook 21(2)). I notice the doctor involved was criticised for “allowing administrative and nursing staff to provide negligent medical advice”. Although not knowing the full case, I assume that the doctor had no knowledge of his administrative staff giving such advice; so I wonder why the doctor is the subject of the claim and not the member of staff involved?

I worry that when I am a consultant I may be deemed responsible for the erroneous actions of a member of staff I do not even know, purely as my name is above the bed

Secondly, with the increasing use of non-medical practitioners to cross-cover several specialties out-of-hours, who would be responsible overall for any errors in a patient’s management? One example would be an error made by a member of the Hospital at Night (H@N) team on a surgical ward. The teams are not usually specialty-specific (as medical staff traditionally are) and the consultant responsible for the patient would not line manage the members of the H@N team or be involved in setting out their roles and responsibilities.

With this case report – and the increasing use of non-medical staff – I worry that when I am a consultant I may be deemed responsible for the erroneous actions of a member of staff I do not even know, purely as my name is above the bed.

Dr Callum Kaye, UK

Response

In the first case which took place in general practice, the GPs who employ practice staff are vicariously liable in law for their acts and omissions. And they would be expected as a matter of good practice to have systems and procedures in place regarding the scope of their responsibilities, as a safeguard against people acting outwith the scope of their knowledge. It would be an unsuccessful defence for the GP to argue that they were unaware of what their staff were doing.

In the hospital setting, whilst each individual is personally responsible (as opposed to liable) for their own actions, any claim would be brought against the hospital, which is liable for the acts and omissions of its employed staff, as well as for any deficiencies in policy and procedure.

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